The volume of the human knee joint

Arthroscopic and open approaches for autologous matrix-induced chondrogenesis repair of the knee have similar results: a meta-analysis

BACKGROUND

Cartilage defects are debilitating injuries that can reduce quality of life in patients. However, the poor regenerative properties of cartilage mean that cartilage repair remains challenging, and many methods have arisen to address that. Autologous matrix-induced chondrogenesis (AMIC®) is a popular technique to manage cartilage defects. Recent advances have allowed AMIC® to be done arthroscopically, instead of a mini-open arthrotomy approach. This systematic review and meta-analysis aims to investigate whether the arthroscopic approach to AMIC® provides better clinical outcomes than does the mini-open approach, in hopes of delineating a gold standard in cartilage repair.

METHODS

With reference to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of the following databases (PubMed, Embase, Scopus, and Cochrane Library) was performed on 26th October 2022 using a combination of the following search terms: "autologous matrix induced", "chondrogenesis", and "knee". A total of 390 studies were identified, of which, 24 studies were included in our final analysis.

RESULTS

The arthroscopic approach achieves lower Visual Analogue Scale for pain scores. The International Knee documentation Committee) score and Knee Injury and Osteoarthritis Outcome Score were comparable between arthroscopic and open approaches. The open approach achieves a higher Magnetic Resonance Observation of Cartilage Repair Tissue score. Incidence of reported postoperative complications of revision surgery and knee stiffness was higher for the open approach than for the arthroscopic approach, whereas deep vein thrombosis was higher in the arthroscopic approach.

CONCLUSION

The AMIC® repair outcomes indicate that the arthroscopic approach does not hold a distinct advantage over the open approach. The choice of approach should consider surgeon expertise, location of lesion, and patient-specific factors.

LEVEL OF EVIDENCE

Systematic review and meta-analysis; Level III.

Long term improvement of knee osteoarthritis after injection of single high/very high volume of very pure PRP: A retrospective analysis of patients optimally managed in dedicated centers

Introduction

PRP is gaining increasing interest for pain relief and improvement of joint function in patients with knee osteoarthritis (KOA) but practices and results remain heterogeneous limiting its adoption as standard of care. Current international recommendations are to collect real-life evidence of efficacy with a systematic monitoring of PRP quality and patients' outcomes. We aimed to analyze the response of patients presenting KOA and treated with standardized PRP injection in routine care. We also investigated the potential contributing factors including patient's phenotype and PRP characteristics.

Methods

Patients with symptomatic KOA and that failed first-line therapy received a single injection of a qualified PRP prepared using medical devices allowing to recover a high/very high volume of very pure PRP. Visual analogue scale (VAS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded at baseline and during 18 months follow-up.

Results

431 patients had available follow-up data at 3 months, 291 at 6 months, 137 at 12 months and 44 at 18 months. PRP induced a significant decrease of WOMAC score at all follow up endpoints (29.2 ± 19.2 at 3 months, p < 0.001 and 25.9 ± 19.7 at 12 months, p < 0.01, compared to 39.7 ± 18.9 at baseline). Similar results were observed for pain VAS (38.9 ± 23.3 at 3 months, p < 0.001 and 35.3 ± 24.1 at 12 months, p < 0.05, compared to 56.0 ± 20.7 at baseline). Changes at 12 months were correlated to baseline scores and to the level of improvement at 3 months. The proportion of OMERACT OARSI responders reached 56.2 % for the total cohort and 60.4 % for severe patients at 6 months. Treatment failure occurred for 8.4 % of patients. Age, BMI or Kellgren-Lawrence grade did not impact on efficacy.

Conclusion

This real-life study evidences the clinical benefit of a standardized high or very high-volume injection of very pure PRP in patients with KOA, including those with a severe grade. It opens perspectives in the positioning of such strategy to delay arthroplasty and provide insights on factors able to anticipate long term efficacy.

The Clinical Effect of Topical Application of Tranexamic Acid in Arthroscopic Synovectomy of Pigmented Villonodular Synovitis of the Knee

This study investigated the clinical effect of topical application of tranexamic acid (TXA) in arthroscopic synovectomy of pigmented villonodular synovitis (PVNS) of the knee. Eighty patients who were diagnosed with unilateral knee PVNS underwent arthroscopic synovectomies from January 2017 to January 2021 and were retrospectively investigated in this study. Patients were divided into two groups: group A was the control group, whereas patients in group B received an intra-articular injection of 50 mL of TXA (1 g:100 mL) immediately after the synovectomies. The primary outcome measurement was the drainage volume of the affected knee in each postoperative stage, as well as the hematological parameters. Secondary outcomes included visual analog scale score, knee range of motion, and Lysholm score. Postoperative complications were also recorded. A lower volume of drainage was found in group B than in group A on postoperative day (POD) 1, on POD 2, and in total (POD 1, P=.000; POD 2, P=.000; total, P=.000). A lower visual analog scale pain score in group B was noticed on POD 1 (P=.000) and POD 2 (P=.005). Range of motion (P=.019) and Lysholm score (P=.001) were significantly superior in group B compared with group A on POD 14. Regarding complications, 3 patients in group A and 1 patient in group B developed deep venous thrombosis after surgery. Hematomas were found intra-articularly in 5 patients in group A during follow-up. Intraarticular topical application of TXA was effective in reducing postoperative bleeding and early postoperative pain for patients who underwent arthroscopic synovectomy of PVNS. [Orthopedics. 20XX;XX(X):xx-xx.].

The effect of intraarticular botulinum toxin-A injection on symptoms of temporomandibular joint disorder

INTRODUCTION

Application of arthrocentesis in temporomandibular joint disorders preferred and suggested therapeutic treatment option in recent years. This study was designed to investigate and compare the effect of intra-articular injection of botulinum toxin-A (Btx-A) on pain and mouth opening after arthrocentesis in nonreduction disc displacement.

MATERIALS AND METHODS

This restrospective study was conducted on 30 patients with a visual analogue scale is higher than five and limited mouth opening. Patients were divided into 2 groups as conventional arthrocentesis group (group A) and intra-articular Btx-A injection following arthrocentesis group (group B). Maximum mouth openining and temporomandibular joint pain were measured in preoperative (t0) and at postoperative 1^st-week (t1), 1^st-month (t2) and 6^th-month (t3).

RESULTS

When VAS scores of group A and group B were examined, no statistical difference was observed at t0 and t1 time intervals; an increased in mouth opening values and decreased VAS score values were observed in both groups in the 1^st month (t2) and 6^{th (}t3) months, mostly in group A.

CONCLUSION

İntra-articular injection of Btx-A following arthrocentesis can induce mouth opening and reduce the pain and dysfunction in patients with anterior disc displacement.

Intra-articular pressure characteristics of the knee joint: An exploratory study

Inflammation-predominant osteoarthritis is an important clinical type of osteoarthritis, with synovitis suggested as its distinct pathophysiology. We investigated whether the synovium's mechanical properties in knees differed by osteoarthritis and other clinical parameters through retrospectively analyzing intra-articular pressure-volume characteristics. We analyzed 60 knees that were administered intra-articular corticosteroids while undergoing pressure monitoring. McMurray's test, pain complaints at end-range knee flexion, Kellgren-Lawrence classification from standing anteroposterior radiographs, and suprapatellar effusion from ultrasound constituted clinical parameters. Pressure-volume profiles-phasic changes in pressure by volume infusion, the volume of Phase 1-the potential volume of the synovial space, the pressure at 45 ml infusion-intra-articular pressure at a standardized volume, and the slope of Phase 2-synovial stiffness were compared with clinical parameters. All graphs were biphasic. Knees with suprapatellar effusion or radiologically definite osteoarthritis (Kellgren-Lawrence grade ≥2), had a lower Phase 1 volume. Knees with definite radiographic osteoarthritis also showed higher pressures at 45 ml and Phase 2 slopes (171.11 ± 94.35 mmHg and 5.08 ± 3.07 mmHg/ml, respectively) than those without (101.88 ± 58.12 mmHg and 2.84 ± 1.27 mmHg/ml, respectively). The Phase 2 slope was higher for knees with positive provocative tests than in those with negative provocative tests, although not statistically significant. The synovium stretched earlier in knees with effusion or radiologically definite osteoarthritis. Intra-articular pressure and synovial stiffness were significantly higher in patients with radiologically definite osteoarthritis. The synovium's mechanical characteristics are altered by osteoarthritis of the knee joint. Intra-articular pressure characteristics could be utilized for synovial evaluation clinically.

Assessment of osteoarthritis functional outcomes and intra-articular injection volume in the rat anterior cruciate ligament transection model

The rat surgical anterior cruciate ligament transection (ACLT) model is commonly used to investigate intra-articular osteoarthritis (OA) therapies, and histological assessment is often the primary outcome measure. However, histological changes do not always correlate well with clinical outcomes. Therefore, this study evaluated functional outcomes in the rat surgical ACLT model and compared intra-articular injection volumes ranging from 20 to 50 μl. Unilateral ACLT was surgically induced and static weight-bearing, mechanical allodynia, motor function, and gait were assessed in four groups of male, Sprague-Dawley rats (n = 6 per group). Intra-articular injections of 20 µl Dulbecco's phosphate-buffered saline (DPBS), 50 µl DPBS, or 50 µl of synthetic biomimetic boundary lubricant were administered once weekly for 3 weeks postoperatively. Structural changes were evaluated histologically at 20 weeks. Rat cadaver knees were injected with 20, 30, 40, or 50 µl of gadolinium solutions and were imaged using magnetic resonance imaging (MRI). Static weight-bearing, mechanical allodynia, and gait parameters in ACLT groups revealed differences from baseline and naïve controls for 4 weeks post-ACLT; however, these differences did not persist beyond 6 weeks. Different intra-articular DPBS injection volumes did not result in functional or histological changes; however, peri-articular leakage was documented via MRI following 50, 40, and 30 µl but not 20 µl gadolinium injections. Statement of clinical significance: Differences in functional parameters were predominantly restricted to early, postoperative changes in the rat surgical ACLT model despite evidence of moderate histologic OA at 20 weeks. Injection volumes of 20-30 µl are more appropriate for investigating intra-articular therapies in the rat knee.

Management of Patients with Adhesive Capsulitis via Ultrasound-Guided Hydrodilatation without Concomitant Intra-Articular Lidocaine Infusion: A Single-Center Experience

Considering the potential chondrotoxic effects of lidocaine, this retrospective study aimed to examine whether ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still provide comparable treatment benefits for patients with adhesive capsulitis (AC). Outpatient data from 104 eligible AC patients who received ultrasound-guided hydrodilatation between May 2016 and April 2021 were reviewed. A total of 59 patients received hydrodilatation with diluted corticosteroid only, while 45 patients received treatment with mixed, diluted corticosteroid and 1% lidocaine. The overall treatment outcome was documented as the percentage of clinical improvement, ranging from 0% to 100% compared to baseline, and it was ranked into poor, moderate and good treatment outcomes. The results show no significant group-wise difference in demographics, overall treatment outcome, and number of hydrodilatations, while most patients showed moderate and good treatment outcomes. Patients with lidocaine infusion did not show greater treatment benefit. Our results suggest that ultrasound-guided hydrodilatation without concurrent lidocaine infusion can still deliver good treatment benefits for AC patients, and the findings are supportive of a modified approach toward careful intra-articular local anesthetic use during management of AC in the primary care setting.

Tranexamic Acid in Combination With Vancomycin or Gentamicin Has a Synergistic Effect Against Staphylococci

Background

Tranexamic acid (TXA) is an antifibrinolytic agent applied in orthopedic surgery and has been proven to reduce post-surgery infection rates. We previously showed that TXA also had an additional direct antimicrobial effect against planktonic bacteria. Therefore, we aimed to evaluate whether it has a synergistic effect if in combination with antibiotics.

Materials and Methods

Three ATCC and seven clinical strains of staphylococci were tested against serial dilutions of vancomycin and gentamicin alone and in combination with TXA at 10 and 50 mg/ml. The standardized microtiter plate method was used. Minimal inhibitory concentrations (MICs) were calculated by standard visualization of well turbidity (the lowest concentration at which complete absence of well bacterial growth was observed by the researcher) and using the automated method (the lowest concentration at which ≥80% reduction in well bacterial growth was measured using a spectrophotometer).

Results

Tranexamic acid-10 mg/ml reduced the MIC of vancomycin and gentamicin with both the standard method (V: 1-fold dilution, G: 4-fold dilutions) and the automated turbidity method (vancomycin: 8-fold dilutions, gentamicin: 8-fold dilutions). TXA-50 mg/ml reduced the MIC of gentamicin with both the standard turbidity method (6-fold dilutions) and the automated turbidity method (1-fold dilutions). In contrast, for vancomycin, the MIC remained the same using the standard method, and only a 1-fold dilution was reduced using the automated method.

Conclusion

Ours was a proof-of-concept study in which we suggest that TXA may have a synergistic effect when combined with both vancomycin and gentamicin, especially at 10 mg/ml, which is the concentration generally used in clinical practice.

Effect of Tranexamic Acid against Staphylococcus spp. and Cutibacterium acnes Associated with Peri-Implant Infection: Results from an In Vitro Study

Tranexamic acid (TXA) is extensively used in orthopedic surgery and traumatology as an antifibrinolytic agent to control intra- and postoperative bleeding and, therefore, indirectly, to reduce postsurgery infection rates. The hypothesis of an additional antibiotic effect against microorganisms associated with periprosthetic joint infection needs to be further evaluated. We aimed to assess whether TXA could reduce bacterial growth using an in vitro model. ATCC and clinical strains of staphylococci and Cutibacterium acnes were tested against TXA in both planktonic and sessile forms. We recorded the percent reduction in the following variables: log CFU/mL by microbiological culture, percentage of live cells by confocal laser scanning microscopy, and, additionally in sessile cells, metabolic activity by the 2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide salt (XTT) assay. Variables were compared between groups using the Kruskal-Wallis test, and the results were reported as median (interquartile range [IQR]). Statistical significance was set at a P value of <0.05. Clinical significance was defined as a reduction of ≥25%. TXA at 50 mg/mL led to a slight reduction in CFU counts (4.5%). However, it was at 10 mg/mL that the reduction reached 27.2% and 33.0% for log CFU/mL counts and percentage of live cells, respectively. TXA was not efficacious for reducing preformed 24-h mature staphylococci and 48-h mature C. acnes biofilms, regardless of its concentration. TXA did not exert an antimicrobial effect against bacterial biofilms. However, when bacteria were in the planktonic form, it led to a clinically and statistically significant reduction in bacterial growth at 10 mg/mL.

IMPORTANCE The possible use of TXA as an antibiotic agent in addition to its antifibrinolytic effect may play an important role in the prevention of prosthetic joint infection.

Knee Capsule Anatomy: An MR Imaging and Cadaveric Study

This research focuses on the anatomical insertion of the synovial capsule around the knee. The attachments of the capsule were measured in 50 knee MR imaging studies with large intraarticular effusion. Corresponding measurements were performed in 20 fresh frozen cadaveric specimens, for validation. Femoral and tibial capsular reflections were defined as the distances between the attachment sites of the capsule and the femoral or tibial joint line and they were recorded in three coronal planes (anterior/middle/posterior). On MR imaging, the lateral/medial femoral capsular reflection mean values were 6.5/4.57 cm, 2.74/1.74 cm and 1.52/1.99 cm in the anterior, middle and posterior plane, respectively. MR imaging-based measurements did not differ significantly compared to corresponding cadaveric measurements. The mean values of the lateral/medial tibial capsular reflection on MR imaging were 0.09/0.11 cm, 0.34/0.26 cm and 0.62/0.34 cm in the anterior, middle and posterior plane, respectively. On cadaveric dissection, the maximum mean value was 1.45 cm, measured on the lateral side of the anterior plane. Apart from the lateral aspect of the posterior plane, MR imaging measurements were significantly lower, compared to the corresponding cadaveric measurements. The greatest femoral and tibial capsular reflections were found on the anterior and lateral side of the anterior plane. MR imaging appears to underestimate the distal extent of the knee capsule. Anatomical details of the knee capsule should be considered for safe insertion of external fixator pins.

Effect of transplanted mesenchymal stem cell number on the prevention of cartilage degeneration and pain reduction in a posttraumatic osteoarthritis rat model

BACKGROUND

Mesenchymal stem cells (MSCs) transplantation therapy is considered an alternative therapy to prevent posttraumatic osteoarthritis (PTOA). However, consensus as to the sufficient number of MSCs for the prevention of PTOA is lacking. The purpose of this study was to determine the sufficient number of MSCs to achieve PTOA prevention and the reduction in pain after anterior cruciate ligament transection (ACLT).

METHODS

Eight-week-old male Wistar rats were used. ACLT was conducted in the knee joint as a PTOA model. According to the species-specific knee joint volume, 10⁴ MSCs in rats are equivalent to 3 × 10⁷ MSCs in humans, which was clinically prepared. MSCs (10⁴, 10⁵, or 10⁶ cells) or phosphate-buffered saline were injected into the knee joint at 1, 2, and 3 weeks after ACLT. Histological examinations were performed at 12 weeks after ACLT. The weight-bearing distribution improvement ratio was calculated as an assessment of pain until 12 weeks after ACLT.

RESULTS

Histological evaluations showed that all the MSCs groups except for 10⁴ MSCs group in femur were significantly improved compared to the control group at 12 weeks after ACLT. The weight-bearing distribution in the 10⁴ and 10⁵ MSCs groups at 12 weeks after ACLT and in the 10⁶ MSCs group at 6, 8, 10, and 12 weeks after ACLT were significantly higher than those of the control group.

CONCLUSION

A clinically feasible number of MSCs was found to reduce the articular cartilage degeneration and to decrease pain in the PTOA model. Increasing numbers of the cells further protected the articular cartilage against degeneration.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair.

Materials and methods

Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant–Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed.

Results

The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant–Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01).

Conclusion

Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Platelet-rich plasma (PRP) in osteoarthritis (OA) knee: Correct dose critical for long term clinical efficacy

Despite encouraging results reported with regards to Platelet-rich plasma (PRP) application in osteoarthritis (OA) knee, still critical issues like conclusive structural evidence of its efficacy, standard dose and good manual method of preparation to obtain high yield remains unanswered. Present study is an attempt to optimise the dose and concentration of therapeutic PRP and its correlation with structural, physiologic efficacy with a new manual method of PRP preparation. A total of one hundred and fifty patients were randomized to receive either PRP (10 billion platelets) or hyaluronic acid (HA; 4 ml; 75 patients in each group) and followed up till 1 year. An addition of filtration step with 1 µm filter in manual PRP processing improved platelet recovery upto 90%. Significant improvements in WOMAC (51.94 ± 7.35 vs. 57.33 ± 8.92; P < 0.001), IKDC scores (62.8 ± 6.24 vs 52.7 ± 6.39; P < 0.001), 6-min pain free walking distance (+ 120 vs. + 4; P < 0.001) persisted in PRP compared to HA group at 1 year. Significant decline IL-6 and TNF-α levels observed in PRP group (P < 0.05) compared to HA at 1 month. Study demonstrated that an absolute count of 10 billion platelets is crucial in a PRP formulation to have long sustained chondroprotective effect upto one year in moderate knee OA.

Hydraulic distension as a treatment for patellofemoral pain syndrome (PFPS) non-responsive to standard rehabilitation

BACKGROUND

The occurrence of Patellofemoral Pain Syndrome (PFPS) is often found in daily medical care. Rehabilitation is usually applied with good results. However, patients often do not respond to standard rehabilitation, suggesting there may be some undetected factors that standard treatments cannot address. It is known that post-traumatic adhesive capsulitis in the knee often shows symptoms similar to those of PFPS, but idiopathic adhesive capsulitis (IAC) has seldom been mentioned as a possible cause of PFPS. Adhesive capsulitis in the shoulder joint causes frozen shoulder (FS), and hydraulic distension (HD) is often applied to FS effectively.

PURPOSE

The purpose of this study was to investigate and report on the clinical application of HD to treat PFPS non-responsive to rehabilitation treatment.

PATIENTS AND METHODS

HD was applied to 72 knees that had resisted regular conservative treatments for PFPS. Follow-up data (e.g. visual analogue scale) was collected immediately after HD, and at periods of 1, 3 and 6 months later.

RESULTS

Of the 72 patients, 64 patients obtained pain relief after HD. Pain was relieved for at least 6 months for 33 of the 64 patients. No benefit was received for 8 patients.

CONCLUSIONS

HD could be an additional conservative option for some PFPS that resisted rehabilitation. Assuming that the mechanisms of action for HD in the knee are the same as those in FS, there is evidence to suggest that IAC might play a role in the development of PFPS for some patients.

Traumatic Arthrotomy

Evaluation of periarticular traumatic wounds for joint penetration is a common clinical concern for orthopaedic surgeons. Wounds that violate the joint capsule can result in deep infection and sepsis. Understanding the anatomic landmarks and capsular extensions of the major joints is key to proper evaluation. Initial evaluation of periarticular wounds includes thorough examination of the wound and plain radiographs. Historically, the saline load test has been the diagnostic test of choice for assessing traumatic arthrotomy; however, CT has recently been shown to have excellent sensitivity and specificity for detecting open knee joint injuries. Current treatment of traumatic arthrotomy includes intravenous antibiotics and surgical irrigation and débridement. Future areas of research must focus on further validation of CT evaluation and its use in other major joints, standardizing antibiotic treatment, and further delineating the role of nonsurgical management in minor injuries.

Volume of the Thumb Carpometacarpal Joint

Background  The volume of the carpometacarpal joint of the thumb (TCMC) and its capacity to accommodate fluid injection is unknown. Questions/Purpose  The purpose of the present study is to assess the volume of the TCMC. Methods  Forty-two thumbs undergoing surgical treatment for symptomatic TCMCJ osteoarthritis (OA) were evaluated. Prior to the start of the surgical procedure saline was injected into the TCMC until resistance was felt and no further saline could be injected. The maximum volume (MaxVol) of injectate was measured and recorded. Results  Mean MaxVol among all patients was 0.9 cc (range: 0.2-3.0 cc). There were 15 patients with 1 cc or more injected, the rest were less than 1 cc. The mean MaxVol for Eaton 2 thumbs was 1.5 cc, for Eaton 3 thumbs 0.9 cc, and for Eaton 4 thumbs 0.7 cc, with negative correlation between Eaton stage and MaxVol. Conclusion  TCMC has limited capacity for injected fluid. Level of Evidence  This is a Level II, diagnostic study.

High- vs Low-Dose Corticosteroid Injection in the Treatment of Adhesive Capsulitis with Severe Pain: A Randomized Controlled Double-Blind Study

Objective

To compare the degree of pain relief between high-dose (40 mg of triamcinolone acetonide) and low-dose (20 mg of triamcinolone acetonide) corticosteroid injections in patients with severe pain due to adhesive capsulitis.

Design

A prospective, randomized, double-blind, dose-comparative study.

Subjects

A total of 32 patients who were diagnosed with adhesive capsulitis and who expressed severe pain intensity, 8 or more points on a numeric rating scale (NRS).

Methods

Patients received injections of high- or low-dose triamcinolone acetonide under ultrasound guidance. NRS, Shoulder Pain and Disability Index (SPADI), and the passive range of motion (PROM) in four directions were evaluated before and three weeks after the injection.

Results

NRS scores showed significant improvement three weeks after the injection in both groups (P = 0.01 in both the low-dose group and high-dose group), but there was no statistically significant difference between the two groups (P = 0.63). SPADI score significantly improved at three weeks after the injection in both groups (P = 0.02 in the low-dose group and P < 0.01 in the high-dose group), but group difference was not observed (P = 0.06). The change of PROM in four directions after the injection did not show any significant difference between the low- and high-dose groups.

Conclusions

Injection of 20 mg of triamcinolone acetonide is sufficient to elicit symptom relief in patients with severe adhesive capsulitis; hence, 20 mg of triamcinolone acetonide can be recommended in patients with adhesive capsulitis with severe pain.

A randomized, controlled study to evaluate the efficacy of intra-articular, autologous adipose tissue injections for the treatment of mild-to-moderate knee osteoarthritis compared to hyaluronic acid: a study protocol

BACKGROUND

Osteoarthritis (OA) is a highly debilitating joint disease that causes progressive, irreversible damage to articular cartilage. OA takes a massive toll on society that has grown in recent decades, but no therapy has been shown to halt or reverse the progression of the disease. The critical need for better treatments and increased interest cellular therapies has spawned a new generation of "minimally manipulated" cell treatments. Autologous adipose tissue injections are among the most controversial of these new treatments. Despite a lack of clinical evidence, adipose tissue injections are often marketed as "stem cell" injections with wide-ranging regenerative benefits. The purpose of this study is to estimate the effect size of the treatment by comparing the efficacy of autologous fat to hyaluronic acid (HA). As a secondary aim, we will test for preliminary evidence of efficacy of autologous fat vs. HA.

METHODS

This is a prospective, single-center, parallel-group, randomized, controlled trial. Participants (n = 54) will receive either a single intra-articular, ultrasound-guided injection of autologous adipose tissue or a single intra-articular, ultrasound-guided injection of HA (1:1 ratio). Outcome data will be obtained at baseline, week-6 and month-6. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain domain (WOMAC-A) will be used as the primary outcome measure. Secondary clinical outcome measures include WOMAC (full), clinical anchors (pain, function, and stiffness), and the 29-point Patient-Reported Outcomes Measurement Information System (PROMIS®) profile. We will also take synovial fluid samples and assess sway velocity using a force plate, as well as analyze excess/discard adipose tissue to gain a better understanding of how intra-articular adipose tissue injections influence the biochemical environment of the joint.

DISCUSSION

Given the widespread use of intra-articular fat injections in the United States, it is critical that randomized, controlled human studies evaluating efficacy and biological activity be performed. This study is the first step in addressing this unmet need, but it is not without limitations. The most notable limitations of this study are its small size and lack of blinding, which predisposes the study to both investigator and participant bias.

TRIAL REGISTRATION

NCT03242707 // HS-17-00365 // Registration Date (First Posted): August 8, 2018.

In vitro susceptibility of Propionibacterium acnes to simulated intrawound vancomycin concentrations

Background

There is convincing evidence supporting the prophylactic use of intrawound vancomycin powder in spinal fusion surgery and mounting evidence in the arthroplasty literature suggesting that it can reduce surgical site infections. As a result, a number of shoulder arthroplasty surgeons have adopted this practice, despite a paucity of evidence and the presence of a pathogen that is, for the most part, unique to this area of the body—Propionibacterium acnes. The purpose of this study was to evaluate the efficacy of vancomycin against planktonic P. acnes in vitro, using time-dependent concentrations one would expect in vivo after intra-articular application.

Methods

Intrawound vancomycin concentrations were interpolated and extrapolated from existing in vivo data. Planktonic P. acnes was then subjected to a time-kill analysis during 96 hours. At each time point, the inoculum was centrifuged into pellet form and then reconstituted for serial drop counts onto blood agar plates. After anaerobic incubation, colony-forming units were counted, and log₁₀ colony-forming units per milliliter were determined.

Results

Early time points grew to confluence, and thus colony-forming units per milliliter were not calculated. However, at 12 hours of vancomycin treatment, distinct colonies were appreciated. Notably, there was a 3 × log₁₀ reduction in colony-forming units per milliliter between 12 and 48 hours, denoting bactericidal activity. In addition, P. acnes was completely eradicated after 3 days of treatment.

Conclusion

When administered in a fashion meant to simulate time-dependent in vivo intrawound concentrations, vancomycin exhibited bactericidal activity against P. acnes. This may lend credence to the prophylactic use of vancomycin in shoulder surgery.